The functional impact of subsyndromal depressive symptoms in bipolar disorder: Data from STEP-BD

Mood Disorders Center, Menninger Department of Psychiatry, Baylor College of Medicine, Houston, TX, United States.
Journal of Affective Disorders (Impact Factor: 3.38). 09/2008; 114(1-3):58-67. DOI: 10.1016/j.jad.2008.07.006
Source: PubMed


This report describes baseline characteristics and functional outcomes of subjects who have prospectively observed subsyndromal symptoms after a major depressive episode (MDE).
All subjects were participants in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). We identified subjects with at least 2 years of observation whose prior or current episode was a MDE, and who were in a stable clinical state of either recovered (no more than 2 moderate symptoms for at least 8 weeks), a MDE by DSM-IV criteria, or with continued subsyndromal symptoms. The subsyndromal group was defined a priori as 3 or more moderate affective symptoms but without meeting diagnostic criteria for major depression.
The final cohort included 1094 recovered, 112 subsyndromal, and 310 individuals in a MDE. The average time spent in each clinical status ranged from 120 to 132 days. The subsyndromal group was most similar to those in a MDE, differing only on the intensity of depressive symptoms and the number of work days missed due to ongoing symptoms. Reported sadness, inability to feel and lassitude were each associated with multiple measures of impairment.
This study is limited by the cross-sectional approach to defining outcomes.
These findings are consistent with studies in unipolar major depression that indicate that functional impairment observed in the context of subsyndromal depressive symptoms is comparable to that of a full episode. This work underscores the need to include subsyndromal symptoms in study outcomes and to target full remission in clinical practice.

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    • "The primary outcome measure, of an improvement in subsyndromal mood symptoms in the Eye Movement Desensitization and Reprocessing group, was met: we found a statistically significant mood stabilizing effect for both depressive and (hypo)manic symptoms in instable bipolar patients at the end of the Eye Movement Desensitization and Reprocessing intervention. Documenting improvement in subsyndromal mood symptoms is of clinical relevance, since these are frequent in bipolar disorder and have been found to be associated with a higher risk of poor outcome on a variety of measures and are difficult to control with medication (Altshuler et al., 2006; Paykel et al., 2006; Judd et al., 2008; Marangell et al., 2009). Also, the study provides a 'proof-ofprinciple' that bipolar disorder is susceptible to treatment with a form of trauma-directed therapy. "
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    • "They had no close friends and almost no social contacts. Interpersonal difficulties in depression have been observed by some previous researchers as well [24, 25]. Thus, depressed patients have relationship problems with both close relations and nonintimates and this does not differ by polarity as our results suggest. "
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    • "QoL, and the boundary between euthymia and subsyndromal symptoms is not always clear (Harvey, 2006; Marangell et al., 2009). Therefore the characterization of the QoL with specific cut-off points in this specific population may provide more clinically meaningful information from the perspective of the patients and their experience of this complex condition as well as of the impact of treatment interventions. "
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    ABSTRACT: BACKGROUND: The relationship between remission and quality of life in bipolar disorder is incompletely understood. This study aimed to determine cut-points on the 36-item Short-Form Health Survey (SF-36) and the European Quality of Life Index (EQ-5D) that corresponded with an objective clinical measure of remission in bipolar disorder patients. METHODS: Data from a 2-year prospective observational study of bipolar and schizoaffective patients were analysed. Concordant with previous research, the Clinical Global Impression-Bipolar Version (CGI-BP) was used as an index of remission, specifically the severity scores of 1 (normal, not at all ill) and 2 (borderline mentally ill). The mean SF-36 standardized mental component (SMC) and standardized physical component (SPC) total scores as well as the EQ-5D index score that corresponded with a CGI-BP severity score of 1 or 2 were determined. RESULTS: The mean SF-36 score that corresponded with a CGI-BP severity score of 1 or 2, was below 50 for the SPC (49.3) and below 49 for the SMC (48.3). The mean EQ-5D score that corresponded with a CGI-BP severity score of 1 or 2 was below 0.88 (0.87). LIMITATIONS: Although the initial sample is sufficiently large (n=240), 49 patients scored 1 and 2 on the CGI-S, of which 12 had schizoaffective disorder. CONCLUSIONS: This study suggests that a cut-off score of ≥50 for the SPC and ≥49 for the SMC of the SF-36 and ≥0.88 for the EQ-5D index approximates a CGI-BP definition of remission.
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